COVID‐19 PANDEMIC ‐ PATIENT SCREENING FORM

If completing form on a cellular device or small screen, view in landscape mode (horizontal screen view) by rotating your phone.

 
 
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
 
 
Are you/they having shortness of breath or other difficulties breathing?
 
 
Do you/they have a cough?
 
 
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
 
 
Have you/they experienced recent loss of taste or smell?
 
 
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should postpone any elective treatment.
 
 
Has ANYONE in your immediate family been caring for a patient diagnosed with Covid-19?
 
 
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
 
 
Have you/they traveled in the past 21 days to any regions affected by COVID-19? (as relevant to your location)
Positive responses to any of these would indicate rescheduling of any treatment.
For testing, see the list of State and Territorial Health Department Websites for your specific area's information.